On The Surgery

Hippocrates

Translated by Francis Adams

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On the Surgery

IT IS the business of the physician to know, in the first place, things similar and things
dissimilar; those connected with things most important, most easily known, and in anywise known; which are to be seen,
touched, and heard; which are to be perceived in the sight, and the touch, and the hearing, and the nose, and the
tongue, and the understanding; which are to be known by all the means we know other things.

2. The things relating to surgery, are — the patient; the operator; the assistants; the instruments; the light,
where and how; how many things, and how; where the body, and the instruments; the time; the manner; the place.

3. The operator is either sitting or standing, conveniently for himself, for the person operated upon, for the
light. There are two kinds of light, the common and the artificial; the common is not at our disposal, the artificial
is at our disposal. There are two modes of using each, either to the light, or from the light (to the side?). There is
little use of that which is from (or oblique to the light), and the degree of it is obvious. As to opposite the light,
we must turn the part to be operated upon to that which is most brilliant of present and convenient lights, unless
those parts which should be concealed, and which it is a shame to look upon; thus the part that is operated upon should
be opposite the light, and the operator opposite the part operated upon, except in so far as he does not stand in his
own light; for in this case the operator will indeed see, but the thing operated upon will not be seen. With regard to
himself when sitting, his feet should be raised to a direct line with his knees, and nearly in contact with one
another; the knees a little higher than the groins, and at some distance from one another, for the elbows to rest upon
them. The robe, in a neat and orderly manner, is to be thrown over the elbows and shoulders equally and proportionally.
With regard to the part operated upon; we have to consider how far distant, and how near, above, below, on this side on
that side, or in the middle. The measure as to distance and proximity is, that the elbows do not press the knees
before, nor the sides behind; that the hands be not raised higher than the breasts, nor lower than so as that when the
breast reposes on the knees he may have the hands at right angles with the arm: thus it is as regards the medium; but
as concerns this side or that, the operator must not be beyond his be beyond his seat, but in proportion as he may
require turning he must shift the body, or part of the body, that is operated upon. When standing, he must make his
inspection, resting firmly and equally on both feet; but he must operate while supporting himself upon either leg, and
not the one on the same side with the hand which he makes use of; the knee being raised to the height of the groins as
while sitting; and the other measures in like manner. The person operated upon should accommodate the operator with
regard to the other parts of his body, either standing, sitting, or lying; so as that he may continue to preserve his
figure, avoid sinking down, shrinking from, turning away; and may maintain the figure and position of the part operated
upon, during the act of presentation, during the operation, and in the subsequent position.

4. The nails should be neither longer nor shorter than the points of the fingers; and the surgeon should practice
with the extremities of the fingers, the index-finger being usually turned to the thumb; when using the entire hand, it
should be prone; when both hands, they should be opposed to one another. It greatly promotes a dexterous use of the
fingers when the space between them is large, and when the thumb is opposed to the index. But it is clearly a disease
when the thumb is impaired from birth, or when, from a habit contracted during the time of nursing, it is impeded in
its motions by the fingers. One should practice all sorts of work with either of with either of them, and with both
together (for they are both alike), endeavouring to do them well, elegantly, quickly, without trouble, neatly, and
promptly.

5. The instruments, and when and how they should be prepared, will be treated of afterwards; so that they may not
impede the work, and that there may be no difficulty in taking hold of them, with the part of the body which operates.
But if another gives them, he must be ready a little beforehand, and do as you direct.

6. Those about the patient must present the part to be operated upon as may seem proper, and they must hold the rest
of the body steady, in silence, and listening to the commands of the operator.

7. There are two views of bandaging: that which regards it while doing, and that which regards it when done. It
should be done quickly, without pain, with ease, and with elegance; quickly, by despatching the without pain, by being
readily done; with ease, by being prepared for everything; and with elegance, so that it may be agreeable to the sight.
By what mode of training these accomplishments are to be acquired has been stated. When done, it should fit well and
neatly; it is neatly done when with judgment, and when it is equal and unequal, according as the parts are equal or
unequal. The forms of it (the bandage?) are the simple, the slightly winding (called ascia), the sloping (sima), the
monoculus, the rhombus, and the semi-rhombus. The form of bandage should be suitable to the form and the affection of
the part to which it is applied.

8. There are two useful purposes to be fulfilled by bandaging: (first,) strength, which is imparted by the
compression and the number of folds. In one case the bandage effects the cure, and in another it contributes to the
cure. For these purposes this is the rule — that the force of the constriction be such as to prevent the adjoining
parts from separating, without compressing them much, and so that the parts may be adjusted but not forced together;
and that the constriction be small at the extremities, and least of all in the middle. The knot and the thread that is
passed through should not be in a downward but in an upward direction, regard being had to the circumstances under
which the case is presented; to position, to the bandaging, and to the compression. The commencement of the ligatures
is not to be placed at the wound, but where the kriot is situated. The knot should not be placed where it will be
exposed to friction, nor where it will be in the way, nor where it will be useless. The knot and the thread should be
soft, and not large.

9. (Second.) One ought to be well aware that every bandage has a tendency to fall off towards the part that declines
or becomes smaller; as, for example, upwards, in the case of the head, and downwards, in the case of the leg. The turns
of the bandage should be made from right to left, and from left to right, except on the head, where it should be in a
straight direction. When opposite parts are to be bandaged together, we must use a bandage with two heads; or if we
make use of a bandage with one head, we must attach it in like manner at some fixed point: such, for example, as the
middle of the head; and so in other cases. Those parts which are much exposed to motion, such as the joints, where
there is a flexion, should have few and slight bandages applied to them, as at the ham; but where there is much
extension, the bandage should be single and broad, as at the kneepan; and for the maintenance of the bandage in its
proper place, some turns should be carried to those parts which are not much moved, and are lank, such as the parts
above and below the knee. In the case of the shoulder; a fold should be carried round by the other armpit; in that of
the groin, by the flanks of the opposite side; and of the leg, to above the calf of the leg. When the bandage has a
tendency to escape above, it should be secured below, and vice versa; and where there is no means of doing this, as in
the case of the head, the turns are to be made mostly on the most level part of the head, and the folds are to be done
with as little obliquity as possible, so that the firmest part being last applied may secure the portions which are
more movable. When we cannot secure the bandaging by means of folds of the cloth, nor by suspending them from the
opposite side, we must have recourse to stitching it with ligatures, either passed circularly or in the form of a
seam.

10. The bandages should be clean, light, soft, and thin. One should practice rolling with both hands together, and
with either separately. One should also choose a suitable one, according to the breadth and thickness of the parts. The
heads of the bandages should be hard, smooth, and neatly put on. That sort of bandaging is the worst which quickly
falls off; but those are bad bandages which neither compress nor yet come off.

11. The following are the object which the upper bandage, the under bandage, or both aim at: The object of the under
bandage is either to bring together parts that are separated, or to compress such as are expanded, or to separate what
are contracted, or to restore to shape what are distorted, or the contrary. It is necessary to prepare pieces of linen
cloth, which are light, thin, soft, clean, having no seams nor protuberances on them, but sound, and able to bear some
stretching, or even a little more than required; not dry, but wetted with a juice suitable to the purpose required. We
must deal with parts separated (in a sinus?) in such wise, that the parts which are raised may touch the bottom without
producing pressure; we must begin on the sound part, and terminate at the wound; so that whatever humor is in it may be
expelled, and that it may be prevented from collecting more. And straight parts are to be bandaged in a straight
direction, and oblique obliquely, in such a position as to create no pain; and so that there may be no constriction nor
falling off on a change of position, either for the purpose of taking hold of anything, or laying the limb; and that
muscles, veins, nerves, and bones may be properly placed and adjusted to one another. It should be raised or laid in a
natural position, so as not to occasion pain. In those cases in which an abscess is formed, we must act in a contrary
way. When our object is to bring together parts which have become expanded, in other respects we must proceed on the
same plain; and we must commence the bringing together from some considerable distance; and after their approach, we
must apply compression, at first slight, and afterwards stronger, the limit of it being the actual contact of the
parts. In order to separate parts which are drawn together, when attended with inflammation, we must proceed on the
opposite plan; but when without inflammation, we must use the same preparations, but bandage in the opposite direction.
In order to rectify distorted parts, we must proceed otherwise on the same principles; but the parts which are
separated must be brought together by an underbandage, by agglutinants, and by suspending it (the limb?) in its natural
position. And when the deformities are the contrary, this is to be done on the contrary plan.

12. In fractures we must attend to the length, breadth, thickness, and number of the compresses. The length should
be that of the bandaging; the breadth, three or four fingers; thickness, three or fourfold; number so as to encircle
the limb, neither more nor less; those applied for the purpose of rectifying a deformity, should be of such a length as
to encircle it; the breadth and thickness being determined by the vacuity, which is not to be filled up at once. The
upper bandages are two, the first of which is to be carried from the seat of the injury upwards, and the second from
the seat of the injury downwards, and from below upwards; the parts about the seat of the injury being most compressed,
the extremities least, and the rest in proportion. The upper bandages should take in a considerable portion of the
sound parts. We must attend to the number, length, and breadth of the bandages; the number must be such as not to be
inferior to what the injury requires, nor occasion compression with the splints, nor prove cumbersome, nor occasion any
slipping of them, nor render them inefficient. As to length and breadth, they should be three, four, five, or six
cubits in length, and as many fingers broad. The folds of the strings (selvages?) should be such as not to occasion
pressure; they are to be soft and not thick; and all these things are to be proportionate to the length, breadth, and
thickness of the part affected. The splints are to be smooth, even, and rounded at the extremities; somewhat less all
along than the upper bandaging, and thickest at the part to which fracture inclines. Those parts where there are
tuberosities, and which are devoid of flesh, such as the ankles or fingers, we must guard from the splints which are
placed over them, either by position, or by their shortness. They are to be secured by the strings in such a manner as
not to occasion pressure at first. A soft, consistent, and clean cerate should be rubbed into the folds of the
bandage.

13. As to the temperature and quantity of the water used, its heat should be just such as the hand can bear, and it
ought to be known that a large quantity is best for producing relaxation and attenuation, whereas a moderate quantity
is best for incarnating and softening. The limit to the affusion is, to stop when the parts become swelled up, and
before the swelling subsides; for the parts swell up at first, and fall afterward.

14. The object on which to (the limb?) is laid should be soft, smooth, and sloping upwards toward the protuberant
parts of the body, such as the heel or hips, so that there may be no projection, nor bending inwards, nor turning
aside. The canal (spout or gutter?) should rather comprehend the whole limb than the half of it, attention being paid
to the injury and to whatever else appears to create inconvenience.

15. The presentation of the injured part to the physician, the extension, the arrangement, and so forth, are to be
regulated according to nature. What is nature in these operations is to be determined by the accomplishment of the
object which we have in view, and for this purpose we must look to the part in the state of rest, in its middle state,
and to habit; in regard to the state of rest and relaxation, as in the arm, that it be in a line with the hand; and
with regard to the medium between flexion and extension, that the forearm be at right angles to the arm; and with
regard to habit, it should be considered that some limbs bear certain positions preferably, as, for example, the thighs
extension; for in such attitudes the parts can best bear to be placed for a considerable time without a change of
posture. And in the change from the state of distention, the muscles, veins, nerves, and bones, when properly arranged
and secured, will preserve their relations to one another while the limb is raised or placed.

16. The extension should be most powerful when the largest and thickest bones, or when both are broken; next when
the under-bone, and least of all, when the upper. When immoderate, it is injurious, except in the case of children. The
limb should be a little elevated. The model by which we judge if the part be properly set is the sound part of the same
name, or the part which is its pair.

18. The following should be the state of matters on the first application of the bandage. The person to whom it has
been applied should say that he feels the compression particularly at the seat of the injury, but very little at the
extremities; the parts should be adjusted but not pressed together, and that rather by the number of the bandages than
by the force of the constriction; and the tightness should rather be on the increase during the first day and night;
but on the next it should be less, and on the third the bandages should be loose. On the next day a soft swelling
should be observed in the extremities; and on the third day, when the bandaging is loosed, the swelling should be found
diminished in size, and this should be the case every time the bandages are removed. At the second application of the
bandage, it should be ascertained whether the dressing has been properly done, and then greater compression should be
made, and with more bandages; and on the third, still greater, and still more. On the seventh day from the first
dressing, when the bandages are loosed, the limb should be found slender and the bones mobile. We must then have
recourse to the splints, provided the limb be free of swelling, pruritus, and ulceration, and allow them to remain
until twenty days after the accident; but if any suspicions arise, the bandages must be loosed in the interval. The
splints should be tightened every third day.

19. The suspending of a fractured limb in a sling, the disposition of it, and the bandaging, all have for their
object to preserve it in position. The principal considerations with regard to the position are the habits and the
peculiar nature of each of the limbs: the varieties are shown in running, walking, standing, lying, action, repose.

20. It should be kept in mind that exercise strengthens, and inactivity wastes.

21. Compression should be produced by the number of bandages, rather than by the force of the constriction.

22. In cases of ecchymosis, contusions, sprains, or swellings not attended with inflammations, blood is to be
expelled from the wound, in greatest quantity to the upper part, and in smallest to the inferior; neither the arm nor
the leg should be placed in a declining position: the head of the bandage should be placed on the wound, and there the
greatest pressure should be made; the least at the extremities, and intermediately in the middle; the last fold of the
bandage should be at the upper part of the body. As to binding and compression, these objects are to be attained rather
by the number of the bandages than the force of the constriction; and moreover, in these cases the bandages should be
thin, light, soft, clean, broad, sound, so that they may effect their purpose, even without splints. And we must use
affusions.

23. Dislocations, sprains, diastases of bones, violent separation, abruption of the extremities of bones, and
distrainings, so as to induce varus or valgus, in these cases we must apply the bandages so as not to compress the part
whence the displacement took place, and that we may render them tight at the side to which the displacement was, and
give the limb an inclination in the opposite direction, and that in an excessive degree. We employ bandages,
compresses, suspension of the limb in a sling, attitude, extension, friction, rectification; and along with these the
affusion of much water.

24. In treating parts which are atrophied, we must comprehend a considerable part of the sound limb with the
bandage, so that by the influx thereby produced, the wasted part may acquire a supply greater than its loss, and may be
thus disposed to growth and restoration of its fleshy parts. It is better also to bandage the parts above, as the thigh
in the case of the leg, and also the thigh and leg of the opposite side, so that they may be placed in similar
circumstances, and may both equally be deprived of motion; and that the supply of nourishment may be alike curtailed
and open to both. The compression should be the effect rather of the number of the bandages than of their tightness. We
relax first the part most requiring it, and have recourse to that kind of friction which will promote the growth of
flesh, and to affusion. No splints.

25. Those things which are for the purpose of giving support and strength to the part, as to the breast, side, head,
and so forth, are used in such cases as the following: for pulsations, that there may be no motion in the part; and in
separation at the sutures of the skull, in order to give support; and in order to strengthen the chest and head, in
coughs, sneezings, and other movements. In all these cases the same measure of bandaging is to be observed, for where
the injury is, there the bandage should compress most, and something soft is to be placed below that suits with the
complaint; and we must not apply the bandages tighter than just to stop the pulsations from creating disturbance, and
that the separated parts at the sutures may be brought into contact, they must not be such as absolutely to stop the
coughs and sneezings, but so as to give support, and, without occasioning uneasiness, prevent the parts from being
shaken.

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